383475_Well Construction - GW1_20100513

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2314A
1 WELL CONTRACTOR
DAVID L REGISTER
Well Contractor (Individual) Name
REGISTER WELL CO., INC
Well Contractor Company Name
721 WEST CHARITY ROAD
Street Address
ROSE HILL
City or Town
910 ) 289-3175
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# 23685
NC 28458
State Zip Code
OTHER ASSOCIATED PERM IT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural D Recovery ❑ Injection 0
Irrigationli Other ❑ (list use)
DATE DRILLED 04/13/10
4 WELL LOCATION
CORNER OF CEDAR PT & EVERGREEN
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY WALLACE COUNTY DUPIN
TOPOGRAPHIC / LAND SETTING (check appropriate box)
0Slope [Walley grFlat ❑Ridge DOther
LATITUDE 34 ° 45 3 6000 "DMS OR 3x XXXXXXXXX DD
LONGITUDE 77 55 23 6000 ° DMS OR 7x XXXXXXXXX DD
Latitude/longitude source VGPS []Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 FACILITY (Name of the business where the well is located )
aUGUSTIN JIMENF7
Facility Name Facility ID# (if applicable)
CEDAR PT AND FVFRGRFFN
Street Address
WAI LACF NC 28466
City or Town State Zip Code
AUGUSTIN JIMFNF7
Contact Name
98 MARILYN COURT
Mailing Address
FNGI FWOOD NJ 07631
City or Town State Zip Code
( .10b 284-1511
Area code Phone number
6 WELL DETAILS.
a TOTAL DEPTH. 160
b DOES WELL REPLACE EXISTING WELLI
c WATER LEVEL Below Top of Casing 8
(Use "+" if Above Top of Casing)
YES NO El
FT
7. CASING:
Top 0
Top Bottom Ft
Top Bottom Ft
3 3
d TOP OF CASING IS 1 .5 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 150 METHOD OF TEST AIR
f DISINFECTION Type HTH Amount 3 07
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
Depth Diameter Weight Material
Bottom 150 Ft 4 40 PVC
8 GROUT Depth Material Method
Top 0 Bottom 20 Ft HOLE PLUG POURED
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth Diameter
Top 150
Bottom 160 Ft 4
Slot Size Material
In 015 in PVC
Top Bottom Ft in in
Top
Bottom Ft in in
10 SAND/GRAVEL PACK
Depth
Top 140 Bottom 160
Top
• Top
Bottom
Bottom
11 DRILLING LOG
Top Bottom
0 / 10
Size
Ft 2
Ft
Ft
Material
GRAVEL
Formation Description
SAND
10 / 12 HARD PAN
12 / 30 CLAY
30 / 75 SAND AND CLAY
75 / 87 ROCK AND SAND
87 / 94 CLAY
94 / 110 ROCK AND SAND
110 / 120 SAND MEDIUM
120 / 135 SAND AND CLAY
135
/ 160+ SAND-MEDIUM-
12 REMARKS
MAY I32010
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT ACOPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL. OWNER
05/10-10
SIGNATURE OF CERTIFIED VVELL CONTRACTOR DATE
DAVID I REGISTFR
• PRINTED NAME OF PERSON CONSTRUCTING THE WELL
rS
Submit within 30 days of completion to: Division of Water Quality - Information Processing A 6, 20
1617 Mail Service Center, Raleigh, NC 27699-161, Phone . [phone] DEC
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arm GW-lb
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